Andropause

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Andropause may or may not actually exist as a clinical phenomenon. Its proponents claim it is a biological change experienced by men during their mid-life, and is often inaccurately compared to the female menopause. It would perhaps be more reasonable to speak of a steady age-related decline in testosterone levels in men, since men's reproductive systems slowly and gradually decline with age, but do not stop working altogether in mid-life, as women's do. It is also not clear how much this supposedly universal male phenomenon can be related to a psychological mid-life crisis, and to overall negative bodily changes in mid-life due not only to aging, but also to the accumulated effects of a lack of exercise, poor diet and so on. Andropause is also known as androgen decline in the aging male (ADAM), late onset hypogonadism (LOH) and testosterone deficiency syndrome (TDS). There is no cut off age at which andropause starts as there is variability among men in terms of age of onset. Endocrine Society Guideline and the European Association of Urology Recommendations defines andropause as the following: TDS/LOH is a clinical and biochemical syndrome associated with advancing age and characterized by symptoms and a deficiency in serum testosterone levels. It may result in significant detriment in the quality of life and adversely affect the function of multiple organ systems.[1]

Historical Perspective

Much of the current interest in this alleged phenomenon has been fueled by the book Male Menopause, written by Jed Diamond[2]. It should be noted that Diamond is neither an MD nor a PhD. According to the book's author, andropause (another term for "male menopause") is a change of life in middle-aged men, which has hormonal, physical, psychological, interpersonal, social, sexual, and spiritual aspects. Diamond claims that this change occurs in all men, generally between the ages of 40 and 55, though it can occur as early as 35 or as late as 65.

The term "male menopause" is a misnomer, as men don’t have menstrual periods, and therefore cannot stop having them. Unlike women, men's reproductive systems do not cease to work completely in mid-life; some men continue to father children late into their lives (at age 90 or older[3]). But Diamond claims that, in terms of other life impacts, women’s and men’s experience are somewhat similar phenomena.[4][5][6]

The concept of andropause is perhaps more widely accepted in Australia and some parts of Europe than it is in the United States[7]. In the U.S., many clinicians believe that, since men can continue to reproduce into old age, and do not show the same dramatic drops in hormone levels characteristic of menopause in women, andropause is nonexistent. Others feel that andropause is real, but is synonymous with hypogonadism or low testosterone levels [8].

Pathophysiology

  • Aging affects the hypothalamus- pituitary- gonadal axis and causes a decrease in the production of gonadotropin releasing hormone (GnRH) by the hypothalamus[9] and a decrease in the production of LH by the pituitary[10].
  • Aging is associated with decrease in the number Leydig cells as well as decrease in their sensitivity to LH resulting in decrease production of testosterone.[11]
  • Age related changes in androgen receptor, a ligand­ inducible transcription factor, has been reported to be associated with less androgenic effects of the testosterone.[12]

Epidemiology and Demographics

The prevalence of andropause has not been accurately reported. According to the Massachusetts Male Aging Study (MMAS) has estimated the crude prevalence of andropause in American men between 40 and 69 years old to be around 481,000 new cases per year.[1]

Screening

Several questionnaires have been developed as a screening tool for andropause. These questionnaires include the following:

  • St. Louis University’s ADAM[13][14]
  • Aging Male Survey (AMS)[15]
  • Massachusetts Male Aging Study questionnaire (MMAS)[16]

Symptoms

The impact of low levels of testosterone has been previously reported. Heller and Myers[17] identified symptoms of what they labeled the "male climacteric" including loss of libido and potency, nervousness, depression, impaired memory, the inability to concentrate, fatigue, insomnia, hot flushes, and sweating. Heller and Myers found that their subjects had lower than normal levels of testosterone, and that symptoms improved dramatically when patients were given replacement doses of testosterone.

Testosterone deficiency has also been linked to metabolic syndrome[18] and mood disturbances mainly depression[19].

Diagnosis

The diagnosis of andropause is difficult since the clinical diagnosis alone or biochemical assays alone are not sufficient. When symptoms of andropause are clinically present along with low or borderline-low free testosterone levels, the diagnosis can be established. According to Morley et al, the diagnosis requires a positive response to testosterone treatment along with the initial clinical and biochemical diagnostic clues.[20].

The biochemical diagnostic clues include measuring the free testosterone level. It is important that the measurement is done in the morning due to the variability of testosterone levels associated with the circadian rhythm[21]. The testosterone measurement should be repeated in two weeks due to week to week variability[22].

Treatment

Several intervention strategies have been found to be effective[23] [24] [25][26]. These include:

  • Hormone replacement therapy,
  • Exercise, dietary changes, stress reduction,
  • Couple counseling, career refocusing, and spiritual support,
  • Chemical dependency treatment, sexual compulsivity treatment,
  • Treatment for depression,
  • Finding and engaging one’s “calling” in the second half of life.

References

  1. 1.0 1.1 Araujo AB, O'Donnell AB, Brambilla DJ, Simpson WB, Longcope C, Matsumoto AM; et al. (2004). "Prevalence and incidence of androgen deficiency in middle-aged and older men: estimates from the Massachusetts Male Aging Study". J Clin Endocrinol Metab. 89 (12): 5920–6. doi:10.1210/jc.2003-031719. PMID 15579737.
  2. Diamond, Jed. Male Menopause. Naperville, IL: Sourcebooks, 1997.
  3. "Father, 90, shows off new baby" - timesonline.co.uk, retrieved 9/08/07
  4. Cetel, Nancy. Double Menopause. New York: John Wiley, & Sons, 2002.
  5. Diamond, Jed. Surviving Male Menopause: A Guide for Women and Men. Naperville, IL: Sourcebooks, 2000.
  6. Tan, Robert S. The Andropause Mystery: Unraveling truths about the Male Menopause. Houston, Texas: AMRED publications, 2001.
  7. Carruthers, Malcolm. Androgen Deficiency in the Adult Male: Causes, Diagnosis and Treatment. London & New York: Taylor & Francis, 2004.
  8. Tan, Robert S. The Andropause Mystery: Unraveling truths about the Male Menopause. Houston, Texas: AMRED publications, 2001.
  9. Morales A, Heaton JP (2003). "Hypogonadism and erectile dysfunction: pathophysiological observations and therapeutic outcomes". BJU Int. 92 (9): 896–9. PMID 14632842.
  10. Liu PY, Beilin J, Meier C, et al. Age­related changes in serum testosterone and sex hormone binding globulin in Australian men: longitudinal analysis of two geographically separate regional cohorts. J Clin Endocri­ nol Metab 2007;92:3599–603.)
  11. Chen H, Hardy MP, Zirkin BR (2002). "Age-related decreases in Leydig cell testosterone production are not restored by exposure to LH in vitro". Endocrinology. 143 (5): 1637–42. PMID 11956144.
  12. Härkönen K, Huhtaniemi I, Mäkinen J, Hübler D, Irjala K, Koskenvuo M; et al. (2003). "The polymorphic androgen receptor gene CAG repeat, pituitary-testicular function and andropausal symptoms in ageing men". Int J Androl. 26 (3): 187–94. PMID 12755998.
  13. Morley JE, Charlton E, Patrick P, Kaiser FE, Cadeau P, McCready D; et al. (2000). "Validation of a screening questionnaire for androgen deficiency in aging males". Metabolism. 49 (9): 1239–42. doi:10.1053/meta.2000.8625. PMID 11016912.
  14. Mohamed O, Freundlich RE, Dakik HK, Grober ED, Najari B, Lipshultz LI; et al. (2010). "The quantitative ADAM questionnaire: a new tool in quantifying the severity of hypogonadism". Int J Impot Res. 22 (1): 20–4. doi:10.1038/ijir.2009.35. PMC 2834355. PMID 19657348.
  15. Morales A, Spevack M, Emerson L, Kuzmarov I, Casey R, Black A; et al. (2007). "Adding to the controversy: pitfalls in the diagnosis of testosterone deficiency syndromes with questionnaires and biochemistry". Aging Male. 10 (2): 57–65. doi:10.1080/13685530701342686. PMID 17558969.
  16. O'Donnell AB, Araujo AB, McKinlay JB (2004). "The health of normally aging men: The Massachusetts Male Aging Study (1987-2004)". Exp Gerontol. 39 (7): 975–84. doi:10.1016/j.exger.2004.03.023. PMID 15236757.
  17. Heller, C.G., Myers, G.B., “The Male climacteric: Its symptomatology, diagnosis and treatment.” JAMA 1944; 126:472-77.
  18. Dandona P, Dhindsa S (2011). "Update: Hypogonadotropic hypogonadism in type 2 diabetes and obesity". J Clin Endocrinol Metab. 96 (9): 2643–51. doi:10.1210/jc.2010-2724. PMC 3167667. PMID 21896895.
  19. DiBlasio CJ, Hammett J, Malcolm JB, Judge BA, Womack JH, Kincade MC; et al. (2008). "Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer". Can J Urol. 15 (5): 4249–56, discussion 4256. PMID 18814813.
  20. Morley JE (2007). "The diagnosis of late life hypogonadism". Aging Male. 10 (4): 217–20. doi:10.1080/13685530701695463. PMID 18033631.
  21. Brambilla DJ, Matsumoto AM, Araujo AB, McKinlay JB (2009). "The effect of diurnal variation on clinical measurement of serum testosterone and other sex hormone levels in men". J Clin Endocrinol Metab. 94 (3): 907–13. doi:10.1210/jc.2008-1902. PMC 2681273. PMID 19088162.
  22. Morley JE, Patrick P, Perry HM (2002). "Evaluation of assays available to measure free testosterone". Metabolism. 51 (5): 554–9. PMID 11979385.
  23. Diamond, Jed. Male Menopause. Naperville, IL: Sourcebooks, 1997.
  24. Diamond, Jed. Surviving Male Menopause: A Guide for Women and Men. Naperville, IL: Sourcebooks, 2000.
  25. Diamond, Jed. The Irritable Male Syndrome: Managing the 4 Key Causes of Depression and Aggression. Emmaus, Pa: Rodale Press, 2004.
  26. Carruthers, Malcolm. Androgen Deficiency in the Adult Male: Causes, Diagnosis and Treatment. London & New York: Taylor & Francis, 2004.

See also

External links


de:Klimakterium virile it:Andropausa he:גיל המעבר אצל גברים uk:Андропауза



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